The National Council on Problem Gambling

730 11th St, NW, Ste 601

Washington, DC 20001

Phone 202.547.9204

Fax 202.547.9206

The screen below provides a simple self test to evaluate your gambling behavior. It is important to note that this self test is not a diagnosis and DOES NOT replace a face to face evaluation with a trained clinical professional. All information is kept strictly confidential. Your answers may be analyzed statistically for research purposes only.

Email address *
Have there ever been periods lasting 2 weeks or longer when you spent a lot of time thinking about your gambling experiences, planning out future gambling ventures or bets, or thinking about ways of getting money to gamble with? *
	Yes No
Have there ever been periods when you needed to gamble with increasing amounts of money or with larger bets than before in order to get the same feeling of excitement? *
	Yes No
Have you ever felt restless or irritable when trying to stop, cut down, or control your gambling? *
	Yes No
Have you tried and not succeeded in stopping, cutting down, or controlling your gambling three or more times in your life? *
	Yes No
Have you ever gambled to escape from personal problems, or to relieve uncomfortable feelings such as guilt, anxiety, helplessness, or depression? *
	Yes No
Has there ever been a period when, if you lost money gambling one day, you would often return another day to get even? *
	Yes No
Have you lied to family members, friends, or others about how much you gamble, and/or about how much money you lost on gambling, on at least three occasions? *
	Yes No
Have you ever written a bad check or taken money that didn't belong to you from family members, friends, or anyone else in order to pay for your gambling? *
	Yes No
Has your gambling ever caused serious or repeated problems in your relationships with any of your family members or friends? Or, has your gambling ever caused you problems at work or at school? *
	Yes No
Have you ever needed to ask family members, friends, a lending institution, or anyone else to loan you money or otherwise bail you out of a desperate money situation that was largely caused by your gambling? *
	Yes No
Demographic Questionnaire Please provide some basic information about yourself. Again, all information you provide is kept strictly confidential and is used only for research purposes. What is your age? *
	select one: Less than 18 18-24 25-34 35-44 45-54 55-64 65+
What is your gender?
	Male Female
What is your race/ethnicity?
	select one: African-American/Black Asian/Pacific Islander Caucasian/White Native American Hispanic Other
Do you gamble on:
	Nothing Bingo Card Games Dice Games Lottery Racing Slots/VLT's Sports Betting
Have you gambled at work or school?
	Yes No
Ever use the internet to gamble?
	Yes No

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